Speaking of Women's Health
The Speaking of Women's Health Podcast is excited to bring you credible women's health information from host and Executive Director, Dr. Holly L. Thacker. Dr. Thacker will interview guest clinicians discussing relevant women's health topics and the latest news and tips.
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Speaking of Women's Health
Endometriosis: Understanding Symptoms, Treatment and Reproductive Health
This episode focuses on the critical aspects of endometriosis, a complex condition affecting millions of women, emphasizing awareness and understanding its symptoms, diagnosis, and treatment options. Host Dr. Holly Thacker discusses the challenges with fertility linked to endometriosis, the importance of early diagnosis, and holistic approaches for symptom management.
• Discussing endometriosis and its prevalence among women
• Common symptoms including pelvic pain and fertility issues
• Challenges in diagnosing endometriosis
• Overview of risk factors and genetic components
• Exploration of treatment options from hormonal therapies to surgery
• The importance of nutritional support and lifestyle changes
• Encouraging open conversations about female reproductive health
• Calls for greater awareness and support for women experiencing endometriosis
Welcome to the Fit, Healthy and Happy Podcast hosted by Josh and Kyle from Colossus...
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Welcome to the Speaking of Women's Health podcast. I'm your host, dr Holly Thacker, the Executive Director of Speaking of Women's Health, and I am back in the Sunflower House for a new podcast, and on this podcast episode, I am going to be talking about endometriosis, as March is Endometriosis Awareness Month, so maybe you know what endometriosis is, maybe you don't, and you think maybe, if I don't think I have it, why should I know about it? You think, maybe, if I don't think I have it, why should I know about it? Well, it's a very perplexing condition in women and it can cause a lot of havoc. And if you're suffering from it, or you think you're suffering from it, maybe it hasn't been diagnosed. So I think it is very important to bring awareness to this female condition. And endometriosis is when the lining of the uterus, the so-called endometrium, grows outside the uterus, and currently, in 2025, when we're taping this, it cannot be cured or prevented completely, but thankfully, the pain and the fertility problems it causes can be relieved.
Speaker 1:And of the more than five and a half million United States American women with endometriosis, 30 to 40% of them have difficulty conceiving. Now, personally, I have experienced endometriosis and had terrible pains and had a little bit of trouble conceiving, but thankfully that's all behind me and, as a lot of long-term listeners know, I have three sons and I am just about to get my fourth grandchild in March, so that's very exciting. So there is certainly hope and fertility is a big issue. Women are putting off child bearing. They feel young, they want to establish their adult life and their careers, but there's really just a very finite period of time that women especially have maximal fertility, and I don't think women hear this enough, and I have taken care of thousands of women over the years and when I've seen younger women, I always ask them and inquire about their childbearing plans and a lot of times they haven't even really thought about it. And since half of all pregnancies can be unplanned and simple things like getting good nutrition and adequate folic acid prior to conception reduces so many neurologic problems, it really is an important discussion to have, even if you don't think that you're going to have children or you're not trying to conceive.
Speaker 1:So, getting back to endometriosis, when you have small islands of tissue that are histologically very similar to the inner lining of the uterus, the endometrium, when they implant themselves on other organs like the abdominal organs, the colon, even potentially the lung. During the cycle of menstruation this ectopic tissue can bleed and cause a lot of painful inflammation. Lot of painful inflammation, severe menstrual cramps can occur, heavy periods, tenesmus, which is painful bowel movements. In fact, the differential diagnosis for tenesmus is endometriosis endometriosis, endometriosis in females. There are other causes, of course. Endometriosis in females. There are other causes, of course, but that really is the primary one.
Speaker 1:Some of the most common places a woman can develop endometriosis includes the space right behind the uterus. It can occur in the muscle of the uterus, adenomyosis, and that's more common in women who've had C-sections, who've had the muscle cut to get the baby out for delivery. There can be deposits on the ovaries which look like chocolate cysts. The dark brown is the dark blood. It can occur in the peritoneum, the lining of the abdomen, the fallopian tubes which if they're scarred or blocked can cause ectopic pregnancy or just definite infertility. Less common places include the rectum, the bladder, the intestines, the diaphragm, that's the muscle that separates the lungs from the abdomen. Actually, there can be ectopic deposits in the vagina. I have seen colon polyps biopsy that are actually endometrial tissue, so it's actually gotten inside the colon and in the lungs. It can be really a problem because during menses if there's bleeding into the lungs, that could actually cause severe pulmonary symptoms and even potentially pneumothorax, where the lung collapses, which can be very dramatic and even potentially life-threatening. So it's a relatively common condition. One in 10 women experience this. Most of the time, healthcare clinicians diagnose it in women in their 20s and 30s and thankfully a lot of the symptoms are manageable with treatment.
Speaker 1:Now the most common symptom is pelvic pain, which can be intense or mild. Symptoms are usually worse just right before and during the period due to the inflammation brought on by the hormonal changes and the bleeding that can occur in the abdomen. Blood is very inflammatory and if blood is present where it shouldn't be, it really sets off a lot of alarms in the body. So very painful menstrual cramps I remember having such pain. I remember telling my family I just wanted a hysterectomy as a teenager, which thankfully I didn't have done Abdominal pain or back pain during the period, heavy bleeding or spotting and of course there's lots of different things that can cause heavy bleeding and abnormal spotting and that always should be evaluated by your women's health care clinician. And if you didn't hear last season's interview with nurse practitioner Kelsey Kennedy on abnormal uterine bleeding. That's a great one to go back to listen to bleeding. That's a great one to go back to listen to.
Speaker 1:Pain during sexual activity. The medical term for that is dyspareunia, which can be deep. There's also superficial dyspareunia. There's vulvar skin conditions that can cause pain with sexual activity, pain that occurs during defecation or urination. Stomach issues, gi issues like diarrhea or constipation or bloating can be more common.
Speaker 1:Some women with endometriosis feel fatigued and they may have some increased risk for anxiety and depression, which are relatively common conditions in women, and a lot of it is lifestyle and nutritional. I have found in my practice, since doing more intense nutritional assessments checking vitamin D levels, b12 and zinc and omega-3, that a lot of minor mood disturbances can really be improved with exercise, good sleep and excellent nutrition. We did a podcast I believe it was season one on food as medicine, and so it's important to be holistic. Some conditions need more than just lifestyle support, but a lot of things can be mitigated or even treated with focusing on a healthy lifestyle. Now, some women really don't have a lot of symptoms.
Speaker 1:It just gets diagnosed when they're undergoing an infertility evaluation. Now you might wonder well, what causes this condition. We're not really sure, but we know that there's probably a genetic component, like with most conditions. So it's always good to know your biological family history conditions. So it's always good to know your biological family history, your mother's history of fertility, which obviously if she had you, she had some degree of fertility. And when I get family histories I mean it's really lovely because people identify the person who helped raise them as their parent or their grandparent. But that's always not biologically the case. So when your physician or nurse practitioner or physician assistant ask you about your mother's health or your father's health or your grandmother's health, they don't mean necessarily the one that you psychologically associate with all that nurturing. Also your, your sister, your sister if you have a full sibling, that's the same sex you share the most DNA with.
Speaker 1:Now it usually starts between ages 20 and 40, but teenagers like myself can experience it Thankfully after menopause. That is one of the things that does improve, because the uterine tissue, the endometrial tissue, gets thinner and you don't have the repetitive cycling of up and down hormone levels. So other risk factors include the family history. For women who have shorter menstrual cycles, and a menstrual cycle can be normal 21 days to up to 42 days. So if your cycle is fewer than 27 days. That's another risk.
Speaker 1:Never having children? It seems like having children not only matures the breast, especially the younger age you have children, which is we think it matures the breast, especially the younger age you have children, which is, we think it matures the breast and makes it more resistant to breast cancer. It also seems to mature the reproductive tract and women who previously had fertility problems with their first baby many of them are surprised to quickly have their second baby. In fact, my second son came 18 months after the first one and I never had a period in between all that time, because the first ovulation was conception. And having very heavy periods as well may also be another risk factor. But there's other things that cause heavy bleeding, including some bleeding disorders and anatomical uterine problems as well. So we can't just assume that it's endometriosis.
Speaker 1:Now diagnosing endometriosis is tricky. The only definitive way currently is through surgery via laparoscopy, where a small little incision is made into the belly button and a lighted scope is inserted to look all around the whole abdomen and pelvis. But this would not be done right off the bat. Certainly a full, complete physical exam and pelvic exam, gynecologic obstetrical history is needed pelvic ultrasound, possibly pelvic MRI, can help make informed decisions. So, getting on to the treatment plan while there's no way to cure it completely, there are ways to treat it. Treatment options that can be very helpful can include hormonal contraceptives being put on. Hormonal contraceptives to quiet the ovaries, to stop the fluctuating hormones, to stop the ovulation and stop the menstrual bleeding can be a godsend to many women. The menstrual bleeding can be a godsend to many women. Other hormonal options elegolix, and sometimes surgery. And sometimes surgery is needed to kind of debulk a lot of endometriosis and sometimes it's used to try to improve fertility.
Speaker 1:Now it does appear that there may be some autoimmune associations with endometriosis. Women with endometriosis are a lot more likely to have Hashimoto's, autoimmune thyroid conditions, and Hashimoto's is relatively common in women one in eight women. If you didn't hear the information season two interview with Dr Ula Abed, our center endocrinologist, on thyroid disorders, that's a great one to listen to and I've been evaluating those conditions and checking the autoimmune status, and anytime I ever diagnose a woman with any autoimmune conditions, I'm also on the lookout for other autoimmune conditions. So with the use of hormonal contraceptives, either oral pills, hormonal patches or the vaginal rings, we have a Nuva ring which lasts for three weeks, and then an Anovera ring which can last for the whole entire year. If you have fewer periods you're going to have less endometriosis bleeding and obviously less pain, and you may even be able to shrink some of that excess endometrial tissue, reduce cramps and help prevent the condition from worsening. And in any woman who has endometriosis and who does want fertility, trying to conceive sooner rather than later is generally the recommendation. And even though there's never a perfect time to have a child, people never seem to have enough time, enough money, enough job security, enough extra help to raise the children. Sometimes you just have to just jump right in, so to speak.
Speaker 1:So hormonal agents that reduce menstruation are very popular choices. The pills contain some sort of a progestin as well as an estrogen substance, occasionally just a progesterone only substance, particularly if the woman cannot take estrogen, if there is blood clots or thrombophilia. The pills are taken daily, or the patch or the ring is generally taken continuously with no placebo break. And if a woman does have breakthrough bleeding, usually the hormone therapies only stop for four days, not longer than that. If a woman, especially a young woman with healthy, robust eggs, goes more than five days without hormonal suppression, ovulation can ensue, so that can lead to pregnancy. That's why when you hear about women who say I faithfully took the pill but got pregnant, generally speaking it's because they had too long a period of off the pill, which could be five days Initially. Some of the longer acting pills that were first fda approved would have a period once a season.
Speaker 1:But there's nothing magical about bleeding. The tissue doesn't build up. You don't have to bleed. And one of my favorite pieces of advice to women if you want to get rid of your blood, please make an appointment to donate blood at the red cross. It doesn't need to be done vaginally. Okay, save on menstrual pads and tampons and pain. So other tips that we recommend to help with endometriosis is have your 25 hydroxy vitamin d level checked, because to help with endometriosis is have your 25-hydroxyvitamin D level checked, because if your levels are low, like they are in lots of women in northern climates and lots of people over age 40, when the skin doesn't convert it as well from natural sunlight, your immune system is going to be off.
Speaker 1:And season one podcast three of the regular podcast season. I mean I did podcast my book, the Cleveland Clinic Guide to Menopause. I did do some continuing medical education credits for physicians and advanced practice providers as well, for free CME, but in terms of my regular Speaking of Women's Health podcast, number three was all about vitamin D and I can't emphasize that enough Regular exercise, taking a B-complex vitamin particularly if you're on hormonal contraceptives where you may metabolize those vitamins faster and eating omega-3 foods at least twice a week. And the more that I check people's levels, the lower the levels I get, even in people who do tell me they eat fish twice a week, and I think some of that is from having too much inflammatory seed oils. And I did do a podcast on omega-3, and I'm going to do an updated one because I have so many women asking me about this. And you have been listening to the Speaking of Women's Health podcast. I am your host, dr Holly Thacker, the executive producer of Speaking of Women's Health. I also run our Specialized Women's Health Fellowship and we've had some of our fellows that are currently in training and some of our esteemed graduates on the podcast, and I also direct our Center for Specialized Women's Health, which is an interdisciplinary center that treats women who have complex problems sometimes that cross different disciplines, that really want a holistic and a focused female evaluation evaluation.
Speaker 1:So moving on to other therapies, intrauterine devices or intrauterine systems out of sight, out of mind. So another option for treating endometriosis is an intrauterine system, an IUS, and this T-shaped device can remain in the uterus for five or more years, releasing low levels of a synthetic form of progesterone, levonorgestrel. Now, that's different than the copper IUD, which I would not recommend if you have heavy periods or painful periods or if you have any copper metabolism imbalance which is pretty rare Wilson's disease but does happen. But the hormonal levonorgestrel intrauterine systems which our center nurse practitioner, dana Leslie, has a great column on IUDs not your grandmother's old IUD, the Dalkon Shield, which was infamous, the Dalkon Shield, which was infamous. That's been off the market for a long, long time.
Speaker 1:So IUDs or IUSs are popular forms of contraception, but we medically use them many times to treat abnormal bleeding and prior to hysterectomy for adenomyosis, when the lining of the uterus grows into the muscle of the uterus. It's used as a stopgap option or possible treatment prior to embarking on hysterectomy. And an intrauterine system does prevent the growth of endometrial tissue and reduces menstrual blood flow, sometimes up to 90% or more. Now for contraception, mirena IUSs are approved for up to eight years. I've seen decidual tissue at that level. I think that's a little bit too long. I personally, if I had one for contraception, would have it removed by six or seven years. But if you're using it to protect the lining of the uterus, to treat endometriosis, to treat pain or heavy bleeding, or to use it in perimenopause when your physician's adding estrogen to treat your hot flashes, then it's only good for five years. Another option is to consider birth control, so-called injections shots administered by your physician or nurse practitioner's office or yourself every three months, containing a potent form of medroxyprogesterone acetate, which can cause later and shorter periods.
Speaker 1:Now there's new warnings on Depo-Provera for an increased risk of a benign brain tumor called meningioma. The baseline rate appears to be about 1 in 10,000 women, but with use of Depo-Provera either to give contraception or to treat menstrual disorders or pain disorders like endometriosis, it is 5 in 10,000 women. So it's still pretty low risk, but it does seem to increase that risk. And when I see women who have meningiomas who maybe have not ever been on Depo-Frovira, a lot of times the tumor is assessed for progestin receptors because that may affect how we treat the woman in terms of premenopausally and postmenopausally if we're using any hormonal options. Now another therapy, if the standard hormonal contraceptives or injections don't work, is. The next level would be injectable monthly luprolide injections, which is a stronger synthetic hormone that suppresses the pituitary from stimulating the ovaries to make eggs. It's like putting someone into a medical menopause. Now the medical treatments can relieve pain but doesn't necessarily improve fertility. So again, women who hope to have their own biological children should let their health care team know sooner rather than later.
Speaker 1:Another option to talk about is oralisa. Another option to talk about is oralisa. The FDA has approved Elagolix E-L-A-G-O-L-I-X, also known as oralisa, for oral treatment of moderate to severe pain associated with endometriosis. So Elagolix is a gonadotropin-releasing hormone, a GnRH antagonist, and it's the first and the only one that's developed specifically for managing this type of pain. Other treatments Danazol, which is an androgen, can treat endometriosis. It's synthetic androgen. It's an effective treatment, but it can cause male-like side effects like increased body hair, acne and weight gain. I've occasionally used Danazol successfully in women with excruciating breast pain that's hormonal and cyclical. It's pretty rare, but it's nice to have this option and it can be used in varying doses and also has some bone benefits.
Speaker 1:So laparoscopy scoping out the problem A outpatient procedure it's done by a surgeon trained in obstetrics and gynecology and minimally invasive skills inserts a very slim viewing tube, called a laparoscope, through a very tiny belly button incision and the outside of the uterus, the ovaries, the fallopian tubes and the pelvic organs. Even the liver and abdomen can be examined with small tissue samples obtained for biopsy to look under the microscope. Now, if the biopsy show that it is endometriosis, surgery might be necessary to relieve the symptoms and improve fertility, and at this time instruments can be inserted through another small incision to remove or destroy the endometrial implants. Now, anytime you insert anything into the abdomen there is a risk of bowel perforation and I have sadly seen a case of a young woman undergoing laparoscopy who had a bowel perforation and died from sepsis. So you know it's not something to be taken lightly and it's very important to have a very experienced operator. And anytime you have any type of invasive procedure done, if there's extreme pain or fever or things don't feel right, you must obtain emergency evaluation and for widespread endometriosis, traditional abdominal pelvic surgery may be needed. Surgery is often successful in relieving pain, especially if hormonal contraceptives are used afterwards, but up to 20% of women need additional pain management afterwards, and some women need urologic intervention with stents if the endometriosis is affecting their ureter. That is the tube that takes the urine from the kidney down into the bladder.
Speaker 1:Women who've totally completed their families may wish to have a hysterectomy, with or without removal of the ovaries. Now, generally speaking, if you're having a hysterectomy for any reason, we usually always recommend recommend that the tubes come out, because most ovarian cancer starts in the tubes and in fact, in the last few years, women undergoing tubal ligations are actually getting complete removal of the tubes, salpingectomies, not only to prevent pregnancy but to prevent ovarian cancer. And women who are at increased risk for ovarian and breast cancer who are not yet ready to have their ovaries removed, sometimes will undergo salpingectomy first while still keeping the hormonal milieu and benefits of the ovaries until they need to have the ovaries removed, and some of it depends on whether it's BRCA1 or BRCA2 or other mutations, what their family history is and their personal preferences. Now, when I do see high-risk women who are too young to get rid of their ovaries, because if you have oophorectomy at a young age, even with hormone therapy, it can increase the risk of neurodegenerative diseases. So we ideally like to keep the ovaries into age 40. Occasionally, with BRCA1 or some family histories, they may need to come out a little bit earlier, but if you can make it to 40, that's ideal. Some women with endometriosis cannot and some can.
Speaker 1:Now, if you're trying to reduce ovarian cancer risk, you need a hormonal contraceptive that suppresses ovulation, which generally would contain some estrogenic substance, whether it's by pill or by patch or by vaginal ring, or a lot of women, especially younger women, really like the Mirena or Lylata or Kylena or IUD for hormonal purposes, and that reduces pain and bleeding and gives excellent contraception but doesn't suppress ovulation. So if you want to suppress ovulation, which in general breastfeeding, pregnancy and that type of hormonal contraception does, you do reduce ovarian cancer risk, even if you're not a gene carrier. You do reduce ovarian cancer risk even if you're not a gene carrier, and since we don't have good therapies to screen for ovarian cancer and ovarian cancer can be deadly, I think it's an important thought for all women and when I'm seeing my patients that are BRCA carriers and they have female children and they're too young to be tested, and we do have a podcast specifically on the GINA law, which anyone who's got a family history of a genetic mutation should definitely listen to, listen to, and the law can certainly change and be updated, but we do have a lot of protections for individuals with genetic mutations, but it's still important to be cognizant of this. Anyway, getting back to me, talking to my midlife patients who have young daughters, I tell them it doesn't matter whether your daughter has the mutation or not. Both sets of women can benefit from ovarian suppression. So once ovulation has been set for a year or two and the bones fuse and there's no more height growth for that female, I think it's good to suppress ovulation, particularly if there's pain, abnormal bleeding or any concern about family history of ovarian cancer. Because if you're not trying to get pregnant, even if you're not sexually active, you could be a woman who's joining the nunnery and going to serve religiously. That is wonderful and fine.
Speaker 1:So it's not just about contraception. There are so many medical, hormonal and cancer-preventing aspects to controlling the hypothalamic, pituitary, ovarian, uterine axis. So we consider generally hysterectomy, removal of the ovaries, kind of as a last resort. And when you do that and you remove the ovaries, you have castration, surgical menopause, regardless of the woman's age. It's not something you go through. You are thrown into it, okay, and there's consequences of losing estrogen naturally with natural menopause, but even more strikingly surgically, because you also lose your testosterone and androstenedione stroma promoting hormones and, for those of you interested in kind of the whole biology and physiology of ovarian hormones. I do cover this in the Cleveland Clinic Guide to Menopause, which I podcasted an updated version of back in season one.
Speaker 1:And even if you remove all visible implants to the naked eye of endometriosis, if you give back estrogen afterwards then there could be growth of those endometrial implants. So surgery is not really completely curative either. Surgery to remove endometrial implants may not even be the solution for all women with fertility issues, because endometriosis can still recur in 20 to 40 percent of all patients within five years and it's one reason why this area is so hotly investigated Now. You still can get pregnant if you have endometriosis. It just might be more of a struggle, and if you don't want to become pregnant, you cannot rely on the fact you have endometriosis either to prevent pregnancy. So it is a common cause of infertility, although age because women are just simply waiting too long is really the big one, and because endometriosis can cause tissue to grow in places where it doesn't belong, that tissue can interfere with how a sperm and an egg move in terms of the dance that they need to join to form a new human being. That occurs during conception. Now in vitro fertilization has been going on now for a few decades and it's certainly an option for patients with endometriosis. It's a highly successful alternative. I'm personally glad that I didn't have to undergo that, but I remember thinking about it and looking into it.
Speaker 1:Ivf generally begins with hormonal treatments which stimulate the ovaries to produce multiple mature eggs. When ready, the mature eggs are collected through an outpatient guided needle biopsy done under some sedation. Then the eggs are exposed to sperm in a culture dish, in the laboratory or through ICSI. A single sperm may be injected into a mature egg, particularly if there are sperm issues. Once the eggs are fertilized, embryo development is closely monitored. Selected embryos that develop are placed into the woman's uterus and then the additional ones, if there's any leftover, can be frozen. And today's IVF does result in very high pregnancy rates, with the transfer of far few embryos that have been done in the past. According to our reproductive endocrinology infertility REI specialist, these are OBGYNs who then go on and do several extra years of training in infertility, so this makes pregnancy generally much safer Other options for future pregnancy. It can allow for eggs just to be frozen on their own and then the eggs defrosted and retrieved for future use.
Speaker 1:This is not nearly as successful, though, as freezing embryo. So I think women have to think long and hard about making personal decisions, and that's something that generally physicians and nurse practitioners are not doing personal counseling in terms of your choices of what type of life you want to have. They're a little bit more focused biologically, and I just have so many women who tell me and are regretful that they did not have their own family and that they just thought that technology or looking at the media and seeing these older stars having children in their 40s and 50s, I can tell you that a lot of times that's because of egg donation, and so that's obviously a gift to donate eggs, you know, just like men can donate semen, which is generally a lot easier process, of course, than donating eggs, which is a much more invasive procedure. So these are all things to think about, and busy young women that aren't even married or are still in college or starting their career aren't necessarily thinking about, but they should be, and so if you do suspect that you have endometriosis, make an appointment with a women's health specialist, especially one that has extra training in fertility. Doesn't necessarily have to be an REI Usually they want you to have tried for at least six months to a year trying to get pregnant, but it probably should be an OBGYN physician and there are many options for treatment and the sooner you're diagnosed, the sooner you can start treatment if necessary, or you can start treatment if necessary.
Speaker 1:So thank you so much for listening to our Speaking of Women's Health podcast. Don't miss future episodes. Hit, follow or subscribe, and you can subscribe on Apple Podcasts, spotify TuneIn wherever you listen to podcasts, and, if you like to see the podcast, we have a Speaking of Women's Health channel on YouTube and one on Rumble. Please share these podcasts with others and leave us a five-star rating, and you can go on speakingofwomenshealthcom and hit donate to donate to our nonprofit. Thanks again and I'll see you next time in the Sunflower House. Remember, be strong, be healthy and be in charge.
